Quality Life Services - Chicora
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicora, Pennsylvania.
- Location
- 160 Medical Center Road, Chicora, Pennsylvania 16025
- CMS Provider Number
- 395118
- Inspections on file
- 35
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 43 (2 serious)
Citation history
Health deficiencies cited at Quality Life Services - Chicora during CMS and state inspections, most recent first.
Surveyors found that a resident dining room near the kitchen was being used to store maintenance equipment and tools, including carts, unattached hand railings, a nail gun, a drill with bits, metal ratchets, scraping tools, a shop vacuum, and fans, while the room’s doors were not locked despite signage stating it was closed. The DON stated there was no policy specific to maintaining a safe, clean, and homelike environment, and a project manager explained that the equipment was related to an ongoing nighttime renovation project and acknowledged that the maintenance equipment had not been secured behind a locked door as required.
A resident with muscle weakness and a need for assistance with personal care sustained superficial burns to the thighs and abdomen after hot tea was spilled during dinner service. Dietary staff poured hot water for beverages without checking temperatures and then moved to the opposite side of the dining room, with their backs turned when the resident cried out. A tablemate reported that a kitchen staff member had just poured hot water into the resident’s cup and then continued serving others before the cup was found tipped over. At the time, two dietary staff were in the dining room and the assigned aide was occupied with another resident, and the NHA confirmed that water temperatures were not checked prior to service, resulting in inadequate supervision and a burn injury.
Surveyors found that a COVID-positive resident with COPD and other conditions was ordered and care planned for droplet precautions per facility policy, which required appropriate signage and a closed door. Observations showed that, although droplet precaution signage was posted, the resident’s door remained wide open to the hallway on multiple checks. An RN acknowledged the door should remain closed to prevent cross contamination, and the DON confirmed the facility failed to follow droplet precautions for this resident.
The facility did not maintain comfortable air temperature levels in a resident room and two common areas, despite having an Extreme Weather policy addressing risks of excessive cold for geriatric residents. After the boiler, the facility’s heat source, required resetting, subsequent observations with the Maintenance Director showed temperatures of 68°F in a resident room, 67.3°F in a common room, and 70.5°F in the dining room. The NHA acknowledged that these conditions did not meet the requirement to provide a safe, comfortable, and homelike environment for residents.
A resident with dementia, depression, and anxiety, care planned as an elopement risk and wanderer, exited a locked memory unit by following their husband, who knew the door code and left the unit without checking behind him. The resident, who was documented as rarely/never understood and did not have a completed BIMS, was later found ambulating in another hallway approximately 36 feet from the memory unit and was returned by staff. Facility records showed behavioral notes without exit-seeking behaviors, and leadership acknowledged that supervision was insufficient to prevent this elopement.
A resident with diabetes and other conditions sustained a burn after being served hot coffee by the Activities department without the temperature being checked, while another resident with dementia and a history of wandering eloped twice due to lack of individualized supervision and interventions. Facility staff and leadership confirmed failures to follow policies on accident prevention and elopement.
The facility failed to ensure all nursing staff received required abuse/neglect education before working and annually, and did not timely identify, report, or investigate allegations that an LPN administered medications without orders, resulting in residents being overly sedated and unable to eat or wake up. The LPN continued to work after allegations were made, and the facility did not promptly suspend the staff member or initiate an investigation.
Staff reported that an LPN was administering medications such as melatonin and Tylenol to residents without proper orders, leading to residents appearing sedated, unable to eat, and an increase in deaths on the memory impaired unit. Despite these reports, facility leadership delayed reporting the allegations to required authorities for ten days, failing to follow mandated procedures for timely investigation and notification.
The NHA and DON failed to implement the facility's abuse and neglect policy and did not report alleged criminal activity involving an LPN to authorities, resulting in immediate jeopardy for all residents. This deficiency was identified through review of job descriptions, records, and staff interviews, and confirmed during an interview with the Chief Nursing Officer.
Four direct care nurse aides did not receive the minimum 12 hours of annual training required by regulation, as confirmed by facility documentation and staff interviews.
A resident with severe cognitive impairment and high fall risk experienced an unwitnessed fall resulting in injury. Despite facility policy requiring prompt notification, the physician was not informed until three days later and the family was notified twenty days after the incident. Staff interviews and documentation confirmed the delay in communication and failure to follow established protocols.
A resident with dementia and anxiety was administered Ativan PRN over an extended period without a 14-day stop date or documented physician rationale for continued use. Non-pharmacological interventions were not documented prior to medication administration, and staff confirmed that facility policy was not followed regarding psychotropic medication use and documentation.
A resident with severe cognitive impairment and multiple diagnoses required substantial assistance with toileting and hygiene. After a fall resulting in injury, the clinical event was documented by the Nursing Home Administrator, who is not a nurse, contrary to professional standards of practice. Staff interviews confirmed that only nursing personnel should document such events.
A resident with cognitive impairment and multiple diagnoses was given PRN acetaminophen for pain without documented evidence of a physical assessment, vital signs, or non-pharmacological interventions prior to administration. Staff interviews confirmed that required assessments and documentation were not completed, and the DON acknowledged the failure to follow facility policy and state regulations.
A resident with severe cognitive impairment and high fall risk experienced a fall while unsupervised during toileting, resulting in injury. Required fall prevention interventions, timely physical assessment, and neurological checks were not implemented as per policy. There were also significant delays in notifying the family and physician, and staff failed to document and monitor the resident as required.
A resident with a documented Tylenol allergy was given Tylenol by an LPN who did not check the chart before administration, resulting in a significant medication error. The error was identified during charting, and facility leadership confirmed the failure to follow medication administration protocols.
The facility did not provide required QAPI training to one direct care staff member, as confirmed by review of education records and staff interviews. This failure was identified during a review of staff development practices and cited under relevant state regulations.
A resident with multiple diagnoses who regularly visited his wife in an attached personal care unit was found outside the skilled facility, prompting a new physician's order requiring staff escort for such visits. The care plan was not updated to reflect the resident's preference for visiting his wife or the new escort requirement, as confirmed by the Nursing Home Administrator.
A resident with heart failure, anxiety, and depression reported being handled roughly by a nurse aide during care, describing the incident as sexual abuse and expressing significant emotional distress. Although the event was reported as physical abuse and the staff member was suspended, the specific allegation of sexual abuse documented by an LPN was not communicated to the DON and was not investigated, resulting in a failure to follow facility policy for abuse investigation.
The facility failed to properly label and date food items and maintain clean equipment in the Main Kitchen, as observed by surveyors. Unlabeled whipped topping, pies, and turkey were found, and a fan used for drying dishes was covered in a gray, fuzzy substance, indicating non-compliance with food safety and sanitation policies.
The facility failed to communicate necessary resident information to the receiving health care provider for five residents transferred to a hospital. The missing documentation included care plan goals, advanced directives, and specific care instructions, despite the residents having conditions like Alzheimer's, diabetes, and coronary artery disease. The Director of Nursing confirmed this failure, violating resident rights.
The facility failed to notify residents or their representatives of the bed-hold policy during hospital transfers or therapeutic leaves for four residents with conditions such as Alzheimer's, dementia, and coronary artery disease. The facility's policy requires written notification at the time of transfer, but no documentation was found to confirm this was done.
The facility failed to reassess a resident for safe smoking practices and did not adequately monitor elopement prevention devices for several residents. A resident with a history of heavy smoking and medical conditions was not reassessed for smoking safety as required. Additionally, Wanderguard devices for residents with cognitive impairments were not monitored according to physician orders, with multiple instances of missed checks. These deficiencies were confirmed by the DON.
The facility failed to lock a medication room refrigerator containing narcotics and did not label open medications with a date. An LPN confirmed these issues. Additionally, medications and treatments were not stored properly on two medication carts, with expired insulin and unlabeled medications found. An LPN acknowledged these deficiencies.
The facility failed to monitor personal refrigerators for two residents, did not implement proper infection control during a dressing change for a resident with paraplegia, and neglected to review infection control policies annually. Additionally, the facility did not notify residents or their representatives about COVID-19 and Norovirus outbreaks, as confirmed by the DON.
Two residents with significant assistance needs were left without timely help during meals, compromising their right to a dignified dining experience. One resident with Alzheimer's and malnutrition required substantial assistance, while another with dementia and diabetes was fully dependent on staff for eating. Observations showed both residents unattended with meals in front of them, while staff were busy assisting others. A nursing assistant admitted to not reporting the need for more staff, and the Assistant Director of Nursing confirmed the deficiency.
A resident with hyperlipidemia and depression developed skin issues, including scratches and a yeast infection. An aide and an RN noted these conditions and applied creams, but the facility failed to notify the physician of the change in condition. This deficiency was confirmed by the DON.
A facility failed to ensure a resident with moderate cognitive impairment understood the SNF ABN form, as required by regulations. The resident, with a BIMS score of 8, signed the form without adequate explanation, violating resident rights and admission policies.
A facility failed to obtain a physician order and develop a resident-centered care plan for placing a resident's bed against the wall. The resident, diagnosed with coronary artery disease, hypertension, and hyperlipidemia, had a care plan to prevent falls, but it did not include the bed placement. This oversight was confirmed by staff and violated facility policy and resident rights, which prohibit restraints without medical necessity.
A resident with an indwelling urinary catheter did not have a privacy cover on their catheter bag, as required by facility policy. The resident, diagnosed with neurogenic bladder, had a physician's order for a foley catheter. An LPN confirmed the absence of the privacy cover during an observation.
Facility staff failed to maintain communication with the dialysis center for two residents, leading to incomplete dialysis communication sheets. An LPN admitted to not filling out the top portion of the sheets, while an RN confirmed the necessity of completing them. The DON acknowledged the deficiency in communication and documentation for the residents receiving dialysis.
A resident did not receive their prescribed Mercaptopurine on two consecutive days due to unavailability, and the physician was not notified of the missed doses. This was confirmed by the DON, indicating a failure to prevent significant medication errors as per facility policy and state regulations.
The facility did not conduct QAA meetings with all required members from January to March 2024. The QAPI Committee, as per policy, should include members like the Medical Director and Infection Preventionist, who were absent. This was confirmed by the Nursing Home Administrator.
The facility failed to provide mandatory effective communication training for a NA, as required by the Employee Handbook. A review of the NA's personnel file showed no documentation of such training over a specified period, which was confirmed by the DON.
A resident with Alzheimer's and anemia, dependent on mechanical lift assistance, was manually lifted by three NAs without using the prescribed mechanical lift, resulting in a shoulder injury. The NAs cited unavailability of equipment and lack of knowledge about the resident's transfer status. The DON and Administrator confirmed the neglect in not using the safest transfer method.
A resident with Huntington's Disease eloped from a facility due to inadequate supervision and failure to adhere to elopement prevention policies. The resident, who was cognitively intact, left the courtyard unsupervised and was found outside. Additionally, another resident with Alzheimer's disease was improperly transferred without a mechanical lift, contrary to their care plan, resulting in shoulder swelling. The facility failed to complete timely risk evaluations and ensure safe transfer practices, as confirmed by the NHA and DON.
The facility did not maintain a clean and safe environment in the Miller's Crossing Nursing Unit shower room. Observations revealed a brown substance on the shower stall wall, debris and grime buildup on the floor, and an unsecured baseboard. These issues were confirmed by the Nursing Home Administrator.
A resident with severe cognitive impairment eloped from the facility due to inadequate supervision. The RN Supervisor and DON failed to complete necessary post-elopement procedures, and the facility's lack of communication and security measures contributed to the incident.
The facility failed to implement policies and procedures to investigate an elopement incident involving a resident with severe cognitive impairment. The RN Supervisor did not complete an incident report or post-elopement assessment, and the facility was unaware of the elopement until the following day. The Director of Nursing confirmed a breakdown in communication and lack of required documentation.
A facility failed to investigate an elopement involving a resident with severe cognitive impairment. The RN Supervisor did not complete an incident report, assess the resident, or update the care plan. The DON confirmed a breakdown in communication and failure to follow policies on neglect and elopement prevention.
The facility failed to update a resident's care plan after the resident, who had severe cognitive impairment, eloped to an unauthorized area. Despite the facility's policies requiring updates to care plans based on ongoing assessments, the RN Supervisor did not assess the resident, complete an incident report, or update the care plan, as the resident was unharmed. The Director of Nursing confirmed this lapse in care planning.
The facility failed to provide adequate supervision for a resident with severe cognitive impairment, resulting in an elopement incident. The RN Supervisor did not complete an incident report or conduct a post-elopement assessment, and the facility was unaware of the elopement until the following day. The resident was able to exit the unit without restricted access, leading to the incident.
Unsecured Maintenance Equipment Stored in Resident Dining Room
Penalty
Summary
Surveyors determined that the facility failed to provide a clean, safe, comfortable, and homelike environment by improperly storing maintenance equipment in an unsecured resident dining room located directly outside the kitchen. During a tour, the dining room was observed to contain maintenance equipment and carts, unattached resident hand railings, a nail gun, a drill with bits, a case of metal ratchets and pieces, scraping tools, a shop vacuum, fans, and other repair tools, while the doors to the room were not secured with locks at either the front or side entrances. Although a sign on the doors indicated the room was closed and to keep doors closed when not in use, the equipment remained accessible in this resident area. The DON reported that the facility did not have a policy specific to maintaining a safe, clean, and homelike environment, and the project manager confirmed that the equipment was related to an ongoing renovation and painting project that had been occurring at night for several weeks to give the facility a makeover, and acknowledged that the facility failed to secure the maintenance equipment behind a locked door as required. No specific residents, medical histories, or clinical conditions were identified in the report as being directly involved in or affected by this deficiency.
Inadequate Supervision and Hot Beverage Handling Resulting in Resident Burn
Penalty
Summary
The facility failed to provide adequate supervision and a safe environment, resulting in a hot liquid burn to one resident. Facility policy on Accidents and Incidents stated that a safe environment would be provided for all residents. The resident involved had diagnoses including high blood pressure, muscle weakness, and a need for assistance with personal care, as documented on an MDS assessment. On the date of the incident, a change in status note recorded that the resident was served a dinner tray, took her tea to drink, and dropped it on herself, resulting in burns to multiple areas including the right thigh, left inner and outer thigh, and right and left lower and upper abdominal quadrants, with specific burn measurements documented. An Emergency Department note stated that a staff member at the nursing home accidentally dropped hot water for tea on the resident, causing a superficial first-degree burn to the upper abdomen and right thigh, with no blistering. Witness statements from dietary staff indicated that hot beverages were poured for residents without checking the temperature of the coffee/tea water, and that the dietary aide was on the other side of the dining room with her back to the resident when the resident cried out. Another statement from the resident’s tablemate reported that a kitchen staff member poured hot water into the resident’s cup, moved on to other tables, and was on the other side of the dining room when the resident screamed and the cup was seen tipped over. The Nursing Home Administrator confirmed that kitchen staff did not check the temperature of the water before service and that, at the time of the incident, two dietary staff were in the dining room while the assigned nurse aide was occupied bringing another resident to the dining room, resulting in inadequate supervision and a burn injury to the resident.
Failure to Maintain Closed Door for Resident on Droplet Precautions
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection prevention and control policy for droplet precautions for one resident on isolation precautions. Facility policy titled "Covid Positive Steps" dated 12/1/25 required that a COVID-positive resident have an appropriate sign on the door, the door remain closed, vitals taken every shift while in isolation, isolation maintained for 10 days, and appropriate PPE stationed by the room. The resident, who had diagnoses including hypertension, COPD, and depression, was admitted on an unspecified date and tested positive for COVID-19 on 3/6/26. Physician orders dated 3/6/26 and the resident’s care plan dated 3/6/26 directed that droplet precautions be maintained every shift. On 3/9/26 at 11:59 a.m., surveyor observation showed that the resident’s door displayed droplet precaution signage but was standing wide open to the outer hallway. At 12:00 p.m., an RN confirmed that the resident was COVID-positive, on droplet precautions, and that the door should remain closed at all times to prevent cross contamination potential. A subsequent observation at 1:17 p.m. again found the door wide open despite the droplet precaution signage. At 1:20 p.m., the DON confirmed that the facility failed to follow droplet precautions for this resident in isolation precautions. The deficiency was cited under 28 Pa Code: 201.14(a), 201.28(b)(1)(e)(1), and 211.10(d).
Failure to Maintain Comfortable Air Temperatures in Resident Room and Common Areas
Penalty
Summary
The facility failed to ensure comfortable air temperature levels in one resident room and two resident common areas, as required by its policy and resident rights to a safe, clean, comfortable, and homelike environment. The facility’s Extreme Weather policy dated 12/1/25 stated that excessive cold for lengthy periods can negatively impact center operations, poses severe potential harm to confused exit-seeking residents, and that geriatric residents are at greater risk of hypothermia because their bodies do not effectively regulate internal temperatures. The Nursing Home Administrator reported that on 1/25/26 the facility’s boiler, which serves as the heat source, needed to be reset. During observations on 1/28/26 from 12:15 p.m. to 12:45 p.m. with the Maintenance Director, air temperatures were measured at 68°F in one resident room, 67.3°F in the Miller Common Room, and 70.5°F in the dining room. In an interview later that day, the Nursing Home Administrator confirmed that the facility failed to ensure comfortable air temperature levels in one of 34 resident rooms and two of three resident areas.
Elopement of Cognitively Impaired Resident From Locked Memory Unit
Penalty
Summary
The facility failed to ensure adequate supervision to prevent an elopement for a resident identified as an elopement risk and wanderer. Facility policy on Elopement Prevention required that residents be properly assessed and care planned to prevent accidents related to wandering or elopement, including completion of a Wandering Risk Assessment upon admission, readmission, quarterly, and as needed, and development of a comprehensive elopement prevention care plan when warranted. The resident’s MDS showed diagnoses of depression, dementia, and anxiety, and Section C0100 indicated the resident was rarely/never understood, with the BIMS not completed. The resident’s care plan, dated 5/22/24, identified the resident as an elopement risk/wanderer based on a history of attempts to leave home unattended prior to admission and included interventions such as identifying patterns of wandering and monitoring the resident’s frequent location. On the date of the incident, documentation showed the resident was observed ambulating outside the locked memory unit on another resident hallway, approximately 36 feet from the memory unit. An interview revealed that the resident’s husband had visited and exited the locked unit, believing the resident was far enough from the door when he left and stating he was in a hurry and did not look behind him. A witness statement from an LPN indicated the resident followed the husband out of the unit and staff later noticed the resident in the hallway and returned the resident to the locked memory unit. Review of progress notes from 6/1/25 through 1/28/26 showed documented behaviors for the resident but none were exit-seeking. The DON stated that when she worked in the locked memory unit, the resident’s husband would come and go because he knew the door code. The NHA and DON confirmed that the facility failed to ensure each resident received adequate supervision, resulting in this elopement event.
Failure to Provide Adequate Supervision Resulting in Resident Burn and Elopement
Penalty
Summary
The facility failed to provide adequate supervision and a safe environment for two residents, resulting in one resident sustaining a burn and another resident eloping from the facility. For the first incident, a resident with diagnoses including diabetes, depressive disorder, and hypertension was admitted to the facility and had physician's orders for restorative dining. During an activity in the dining area, coffee provided by the Activities department was served without checking its temperature. The resident spilled the coffee in her lap, resulting in a red, blistered burn. The incident was reported by a CNA, and it was confirmed that the coffee temperature was not measured prior to serving. In the second incident, a resident with anemia, renal insufficiency, and vascular dementia, who had a known history of wandering and was assessed as an elopement risk, was not provided with adequate supervision or individualized interventions to prevent elopement. The resident's baseline care plan did not include specific interventions for supervision or elopement prevention. Despite being fitted with a wander guard, the resident was able to remove it and eloped to another unit within the facility. On a subsequent occasion, the resident exited the facility through the front doors, triggered the wander guard alarm, and was found outside by another resident's family member. Staff interviews, facility policy reviews, and documentation confirmed that the facility did not follow its own policies regarding accident prevention and elopement. The Director of Nursing and the Nursing Home Administrator acknowledged the lack of adequate supervision and failure to implement resident-centered interventions for the identified elopement risk, as well as the failure to ensure a safe environment in the dining area, which resulted in the resident's burn.
Failure to Educate Staff and Timely Respond to Abuse/Neglect Allegations
Penalty
Summary
The facility failed to ensure that all nursing staff were educated on abuse and neglect prior to working in the facility and annually, as required by policy. Specifically, one LPN did not receive abuse/neglect education before starting work, and two other nursing staff members did not receive annual abuse/neglect education. This lack of training was confirmed through review of employee files, facility documents, and staff interviews. Additionally, the facility did not complete required onboarding documentation for agency staff prior to their start date. Multiple staff members reported concerns regarding the actions of an LPN working on the memory impaired unit, including allegations that the LPN administered medications such as melatonin and Tylenol to all residents regardless of physician orders. Staff observed that residents appeared more sedated, lethargic, and unable to eat or wake up during the day when this LPN was on duty. There were also concerns raised about an increase in resident deaths and changes in resident conditions, such as hypothermia, that were not properly reported or followed up by nursing staff. Despite these reports, the facility failed to identify, report, and investigate these allegations of abuse and neglect in a timely manner. The facility allowed the LPN who was the subject of abuse/neglect allegations to continue working after the concerns were reported, without immediate suspension or implementation of a supervision plan. The Director of Nursing and Nursing Home Administrator confirmed that they did not initiate an investigation or report the allegations to appropriate agencies promptly. Witness statements and interviews revealed that staff were aware of the allegations but did not report them immediately, and the facility did not obtain witness statements until several days after being notified of the concerns.
Removal Plan
- Review current medical records for any signs of abuse/neglect and interview all interviewable residents for any signs and/or symptoms of abuse and/or neglect. If any is found, follow abuse policy and begin investigation and reporting immediately.
- Interview all staff for allegations of abuse/neglect that have not been reported. If any are identified, begin investigations and reporting immediately.
- Provide education by the Chief Nursing Officer to the Director of Nursing and Nursing Home Administrator on immediate reporting of any allegation/neglect.
- Provide education by the Chief Nursing Officer to the Director of Nursing and Nursing Home Administrator on the immediate suspension of an employee with an allegation of abuse/neglect.
- Provide education by the DON/Designee to Licensed Nursing Staff both in house and agency on the appropriate medication administration and following Physician's orders.
- Audit each resident's Medication Administration Record (MAR) and Treatment medication Record (TAR) to ensure medications and treatments have been administered/given as ordered.
- Review the Abuse/Neglect Policy and update if needed.
- Educate all house staff and agency staff on the abuse/neglect policy and reporting abuse by the DON and/or designee.
- Review all audits and policy changes related to immediate jeopardy at an ad hoc Quality meeting.
- Interview all staff for instances of abuse/neglect that were not reported. Report and investigate any incidents timely.
- Require all licensed nursing staff, not educated, to verify education on physician orders and MAR/TARs.
Failure to Timely Report and Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to identify and timely report criminal allegations of abuse and neglect involving an LPN to local law enforcement and required agencies. Multiple staff members, including housekeepers and nurse aides, reported concerns that the LPN was administering medications such as melatonin and Tylenol to residents without proper orders, resulting in residents appearing sedated, lethargic, and unable to eat or remain awake during the day. Staff also noted an increase in resident deaths on the memory impaired unit during shifts when the LPN was working. These concerns were documented in witness statements and interviews, with specific observations of residents' abnormal behavior and changes in condition, such as hypothermia and excessive sleepiness. Despite these serious allegations and observations, the facility did not promptly initiate an investigation or report the incidents to the Area Agency on Aging, the Department of Health, or local law enforcement as required by state law and facility policy. The Director of Nursing and Nursing Home Administrator were made aware of the allegations but delayed reporting for ten days, only notifying authorities after being prompted during the survey process. The DON dismissed the initial reports as hearsay and gossip, contributing to the delay in addressing the allegations. The failure to act on staff reports and to follow mandated reporting procedures resulted in an immediate jeopardy situation, as the facility did not ensure the protection of residents from potential abuse or neglect. The deficiency was identified through review of facility documentation, staff interviews, and examination of resident records, which confirmed that the facility did not comply with legal and policy requirements for timely reporting and investigation of suspected abuse and neglect.
Removal Plan
- Review current residents' medical records for signs of abuse/neglect by the DON and/or designee. Interview all interviewable residents for any signs and/or symptoms of abuse and/or neglect. If any allegations of abuse/neglect are found, follow abuse policy, and begin investigation and reporting immediately.
- Interview staff for review of abuse/neglect allegations that have not been reported to the DON and/or designee. If any allegations are identified, begin investigation and reporting immediately.
- Update review of Electronic event report for neglect allegation by the DON/designee to accurately reflect concern for Nurse giving Tylenol and Melatonin to all residents on the memory unit whether there is an order or not thus causing potential harm.
- Review Abuse/Neglect Policy, Incidents and Accidents Policy, and reporting criteria by NHA and/or designee and update if needed.
- Educate all house staff and agency staff on the abuse/neglect policy and reporting abuse by the DON and/or designee prior to their next shift worked.
- Audit all residents who have had an allegation of abuse/neglect in the last 30 days by the DON and/or designee to ensure that it was reported appropriately and timely.
- Review all audits and policy changes related to IJ 609 at an Ad hoc Quality meeting.
Failure to Implement Abuse Policy and Report Alleged Criminal Activity Creates Immediate Jeopardy
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to effectively manage and implement the facility's abuse and neglect policy, and did not report alleged criminal activity involving an LPN to the appropriate authorities. This failure was identified through a review of job descriptions, clinical records, and staff interviews. The NHA's job description required oversight of day-to-day operations, ensuring compliance with federal, state, and local standards, and maintaining effective systems for resident care and safety. The DON's responsibilities included nursing management, setting care standards, and ensuring regulatory compliance. Despite these outlined duties, both the NHA and DON did not fulfill their essential roles in upholding the facility's policies and legal requirements. As a result of these actions and inactions, all 95 residents were placed in an immediate jeopardy situation. The facility did not implement its abuse and neglect policy and failed to report the alleged criminal activity, as required by regulations. The deficiency was confirmed during an interview with the Chief Nursing Officer, who was notified of the failures by the NHA and DON. The report cites specific Pennsylvania Codes related to the responsibilities of the licensee, management, and nursing services, which were not adhered to in this instance.
Failure to Provide Required Annual Nurse Aide Training
Penalty
Summary
The facility failed to provide the required minimum of 12 hours of annual training for nurse aides, as mandated by regulations. Review of the job description and facility documents confirmed that nurse aides are expected to attend all assigned in-service classes. However, documentation for four direct care nurse aides did not show evidence of completing the required annual training hours. During staff interviews, the Chief Nursing Officer confirmed that these nurse aides did not receive the mandated training for the calendar year reviewed.
Failure to Timely Notify Physician and Family After Resident Fall
Penalty
Summary
The facility failed to ensure timely notification of a physician following a resident's change in condition after a fall. According to the facility's policy, licensed nurses are required to promptly assess and notify the physician and family when a resident experiences a change in condition. In the case reviewed, a resident with severe cognitive impairment, high risk for falls, and multiple diagnoses including anxiety, muscle weakness, and hypertension, experienced an unwitnessed fall while attempting to transfer from the toilet. The resident sustained a skin tear and reported pain and dizziness. Although the incident was documented and the resident's family was eventually notified, the physician was not informed until three days after the fall, and the family was notified twenty days later, contrary to facility policy and regulatory requirements. Staff interviews confirmed that the expected protocol was immediate notification of both the physician and family following such incidents. Documentation revealed inconsistencies in communication and a lack of timely documentation regarding the incident and subsequent actions. The failure to notify the physician and family in a timely manner was acknowledged by both nursing staff and the facility administrator, confirming noncompliance with established resident care policies and state regulations.
Failure to Prevent Unnecessary Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medication. Clinical record review showed that a resident with diagnoses of dementia, anxiety, and high blood pressure was prescribed Ativan 0.5 mg every six hours as needed for a period of three months. The physician's order did not include a required 14-day stop date, nor was there any documented rationale for extending the medication beyond 14 days. The resident received Ativan on 27 occasions in one month and 22 occasions in the following month. Additionally, there was no documentation in the resident's progress notes indicating that non-pharmacological interventions were attempted prior to administering the Ativan. Staff interviews confirmed that facility policy requires the use of non-pharmacological interventions before administering psychotropic medications and mandates documentation of both the interventions and the behaviors. The Chief Nursing Officer acknowledged that the facility did not ensure the resident's medication regimen was free from unnecessary psychotropic medication.
Non-Nursing Staff Documented Clinical Event in Resident Record
Penalty
Summary
The facility failed to follow professional standards of practice in documentation for one resident. A resident with diagnoses of anxiety, muscle weakness, and high blood pressure, and with a severe cognitive impairment, required substantial assistance with toileting and hygiene. The resident experienced a fall while attempting to transfer from the commode to a wheelchair, resulting in a skin tear and headache. The incident was documented as a late entry progress note by the Nursing Home Administrator, who is not a nurse. Interviews with facility staff confirmed that documentation of clinical events should not be completed by non-nursing personnel, and that the Nursing Home Administrator was not authorized to enter such notes. This failure to adhere to professional standards of documentation was identified for one of eight residents reviewed, as supported by facility policy review, resident record review, and staff interviews.
Failure to Provide Non-Pharmacological Interventions and Assessment Prior to PRN Pain Medication
Penalty
Summary
The facility failed to ensure that a resident was provided with non-pharmacological interventions and a proper assessment prior to administering as-needed pain medication. According to facility policy, all residents should be screened and assessed for pain, with documentation of interventions and responses, especially for those who are cognitively impaired or unable to communicate effectively. In this case, a resident with diagnoses including anxiety, Alzheimer's disease, and high blood pressure, who was unable to verbalize pain, was administered PRN acetaminophen for a reported pain level of 7/10. The clinical record did not show evidence that a physical assessment or vital signs were obtained prior to the administration, nor that non-pharmacological interventions were attempted or documented before giving the medication. Further review of the resident's clinical record revealed that after the administration of acetaminophen, the resident's pain was reassessed and found to be zero. However, later that same day, the resident exhibited a significant change in condition, including a low rectal temperature, bradycardia, hypotension, and unresponsiveness. The nurse notified the family and the resident was sent to the emergency room, where they were admitted for altered mental status and a urinary tract infection. Staff interviews confirmed that the required assessments and documentation of non-pharmacological interventions were not completed prior to administering the PRN medication. Staff interviews also indicated that the resident typically exhibited behaviors such as yelling out and clenching fists, which were used as non-verbal indicators of pain. However, the LPN responsible for administering the medication could not recall if non-pharmacological interventions were implemented or documented prior to giving the acetaminophen. The DON confirmed that the facility did not ensure the resident received non-pharmacological interventions and an assessment before administering pain medication as required by facility policy and state regulations.
Failure to Implement Fall Prevention and Post-Fall Monitoring
Penalty
Summary
The facility failed to implement fall prevention interventions and conduct post-fall monitoring for a resident identified as high risk for falls. The resident had diagnoses including anxiety, muscle weakness, and high blood pressure, and was assessed as having severe cognitive impairment and requiring substantial assistance with toileting and transfers. The care plan specified the use of bed/chair alarms and assistance with toileting every two hours, but these interventions were not consistently implemented. An incident occurred in which the resident fell in the bathroom while attempting to transfer from the toilet to the wheelchair without adequate staff assistance. The fall resulted in a skin tear and complaints of dizziness and headache. Although the facility's policy required immediate physical assessment, timely documentation, and prompt initiation of neurological checks after a fall, these actions were not completed as required. Neurological checks were not started until nearly a day after the fall, and there was no evidence of a timely physical assessment or Q15 minute checks in the clinical record. Additionally, there were significant delays in notifying the resident's family and physician about the fall, with the family being notified 20 days later and the physician three days after the incident. Staff interviews confirmed that required assessments and documentation were not completed promptly, and that staff were unclear about their responsibilities regarding post-fall monitoring and communication. These failures resulted in noncompliance with facility policy and state regulations regarding accident prevention and resident care.
Failure to Prevent Significant Medication Error Due to Allergy
Penalty
Summary
A resident with diagnoses including dementia, aphasia, and malnutrition, and a documented allergy to Tylenol, was administered Tylenol by an LPN without a physician's order and despite the allergy being noted in the clinical record. The LPN did not review the resident's chart prior to administering the medication. The error was discovered when the nurse began charting the administration, at which point it was realized that Tylenol was both not ordered and listed as an allergy for the resident. Facility policy requires that medications be administered as prescribed, following the five rights of medication administration, and that staff verify these rights at multiple points during the process. In this incident, the LPN failed to adhere to these protocols, resulting in a significant medication error. The event was confirmed by both the LPN involved and the Chief Nursing Officer during interviews.
Failure to Provide QAPI Training to Direct Care Staff
Penalty
Summary
The facility failed to provide mandatory Quality Assurance and Performance Improvement (QAPI) training to one of five direct care staff members reviewed. According to the Nursing Assistant job description, staff are required to attend all assigned in-service classes and complete assignments. Review of facility education documents for the year 2024 showed that one nurse aide did not receive QAPI training. This was confirmed by the Chief Nursing Officer during staff interviews, who acknowledged that the required training had not been provided to the identified staff member. The deficiency was cited under 28 Pa. Code: 201.14(a) Responsibility of Licensee and 28 Pa. Code: 201.20(a) Staff Development.
Failure to Update Care Plan After Change in Resident Status
Penalty
Summary
The facility failed to revise the care plan for a resident to accurately reflect the resident's current status and preferences. The resident, who was alert and oriented, had a history of high blood pressure, muscle weakness, and malnutrition. Documentation showed that the resident regularly visited his wife in the attached personal care unit, Vista, and was found there by staff after being reported missing from the skilled facility. Following this incident, a physician's order was obtained allowing the resident to visit his wife if escorted by staff, and both staff and the resident were educated on this requirement. Despite these developments, the resident's care plan was not updated to include his preference for visiting his wife or the new requirement for staff escort during these visits. This omission was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the care plan had not been revised as required by facility policy and regulatory standards.
Failure to Investigate Sexual Abuse Allegation per Policy
Penalty
Summary
The facility failed to implement written policies and procedures to ensure a complete and thorough investigation of an allegation of sexual abuse for one resident. The facility's policy requires immediate notification of the Nursing Home Administrator (NHA) or Director of Nursing (DON), reporting to the state health department, contacting the County Area Agency on Aging, and conducting an internal investigation for all abuse allegations. However, documentation and interviews revealed that a specific allegation of sexual abuse was not fully investigated as required by policy. A resident with diagnoses of heart failure, anxiety, and depression reported being handled roughly by a nurse aide during incontinence care, describing the experience as extremely painful and humiliating. The resident stated that the incident felt like sexual abuse and expressed ongoing emotional distress. The event was initially reported as physical abuse, and the involved staff member was suspended pending investigation. The resident was assessed for physical injury, and law enforcement was contacted. However, the specific allegation of sexual abuse, as documented in a behavior note by an LPN, was not communicated to the DON and was not included in the facility's investigation. Interviews with staff confirmed that the LPN who documented the resident's statement about sexual abuse did not recall reporting it to anyone, and the DON stated she was unaware of the sexual abuse allegation. As a result, the facility did not conduct a complete and thorough investigation into the sexual abuse allegation, failing to follow its own policies and procedures for abuse prevention and investigation.
Deficiencies in Food Storage and Equipment Cleanliness
Penalty
Summary
The facility failed to adhere to its policies on food storage and cleaning, leading to deficiencies in food safety and sanitation. During observations in the Main Kitchen, it was noted that several food items, including packages of whipped topping, lemon meringue pies, and sliced turkey, were not properly labeled and dated as required by the facility's food storage policy. This oversight was confirmed by the Dietary Supervisor. Additionally, a fan used to dry clean dishes was found to be covered in a gray, fuzzy substance, indicating a failure to maintain clean equipment. This was confirmed by a Registered Dietitian, highlighting a breach in the facility's cleaning and sanitation policy designed to prevent foodborne illness.
Failure to Communicate Resident Information During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider for five out of six residents who were transferred from the facility to a hospital and expected to return. The facility's policy, dated 7/22/24 and last reviewed on 11/8/24, required that a transfer form be completed and appropriate documentation be sent with the resident. However, upon review of the clinical records for Residents R2, R13, R82, R83, and R88, there was no documented evidence that the facility had communicated specific information to the receiving health care provider. This information should have included the residents' care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the residents' specific needs at the receiving facility. The residents involved had various medical conditions, including high blood pressure, Alzheimer's disease, diabetes, muscle weakness, depression, anemia, dementia, coronary artery disease, and hyponatremia. Despite these conditions, the facility did not provide the necessary documentation to ensure continuity of care during the transfers. The Director of Nursing confirmed during an interview that the facility failed to communicate the required information for these residents, which is a violation of resident rights as per 28 Pa. Code 201.29 (a) (c.3) (2).
Failure to Notify Residents of Bed-Hold Policy
Penalty
Summary
The facility failed to notify residents or their representatives of the bed-hold policy during hospital transfers or therapeutic leaves for four residents. The facility's policy requires that residents be informed in writing about the bed-hold policy at the time of transfer. However, upon review of clinical records, it was found that there was no documented evidence that this information was provided to the residents or their representatives for the specified transfers. The residents involved had various medical conditions, including high blood pressure, Alzheimer's disease, dementia, diabetes, and coronary artery disease. Despite these conditions, the facility did not adhere to its policy of notifying the residents or their representatives about the bed-hold policy during their transfers to hospitals or therapeutic leaves. This deficiency was confirmed by the Director of Nursing during an interview.
Failure to Assess Smoking Safety and Monitor Elopement Devices
Penalty
Summary
The facility failed to assess a resident for safe smoking practices and did not adequately monitor elopement prevention devices for several residents. Resident R42, who has a history of smoking three packs a day and medical conditions including coronary artery disease, hypertension, and hyperlipidemia, was not reassessed for safe smoking after the initial assessment on 6/10/24, despite facility policy requiring such assessments upon admission, quarterly, and as needed. The Director of Nursing confirmed that no further assessments were completed for Resident R42 as required. Additionally, the facility did not ensure proper monitoring of Wanderguard devices for Residents R67, R69, and R72, all of whom have cognitive impairments such as dementia. Physician orders required weekly checks of the Wanderguard battery percentage and checks of placement, function, and skin integrity every shift. However, records show multiple instances where these checks were not completed as ordered, with specific dates and shifts noted for each resident. The Director of Nursing confirmed the failure to monitor these devices as required. These deficiencies indicate a lack of adherence to facility policies and physician orders, potentially compromising resident safety. The facility's policies on smoking assessments and elopement prevention were not followed, leading to lapses in monitoring and assessment that were confirmed by the Director of Nursing during interviews.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that a medication room refrigerator containing narcotics was properly locked and that open medications stored in the refrigerator were labeled with a date upon opening. During an observation, it was found that the refrigerator in the [NAME] Crossings Medication Room was unlocked and contained three opened boxes of Lorazepam and an undated vial of Tubersol solution. An LPN confirmed these findings, acknowledging the failure to secure the refrigerator and properly label the medications. Additionally, the facility did not store medications and treatments properly to prevent cross-contamination on two medication carts. Opened tubes of Biofreeze gel and an Albuterol inhaler were found on a medication cart without proper labeling. Furthermore, expired insulin medications and medications not stored in pharmacy-labeled bags were found on Settlers Cart 6. An LPN confirmed the presence of expired medications and the lack of proper labeling, indicating a failure to adhere to storage and labeling protocols.
Infection Control and Communication Deficiencies
Penalty
Summary
The facility failed to properly monitor the personal refrigerators of two residents, as neither contained a thermometer or a temperature log for daily monitoring. This oversight was confirmed by an LPN during interviews and observations. Additionally, the facility did not implement proper infection control practices during a dressing change for a resident with paraplegia, diabetes, and depression. The LPN involved did not clean the bedside stand or place a barrier before placing dressings, used ungloved hands to place a barrier under the resident, and did not perform hand hygiene after cleansing the wound and applying new dressings. The facility also failed to review its infection control policies annually, with the last review dated back to 2014. Furthermore, the facility did not notify residents or their representatives about two infectious outbreaks, COVID-19 and Norovirus, as confirmed by the Director of Nursing. The resident group was unaware of the Norovirus outbreak, indicating a lack of communication from the facility regarding these health concerns.
Failure to Provide Timely Meal Assistance
Penalty
Summary
The facility failed to provide a dignified dining experience by not offering timely assistance with meals to two residents, R35 and R55. Resident R35, who has diagnoses of depression, malnutrition, and Alzheimer's disease, requires substantial maximal assistance with eating, as indicated by their MDS assessment. During an observation, it was noted that Resident R35 was left without assistance at a dining table with their meal in front of them, while four staff members were occupied assisting other residents. Similarly, Resident R55, who has high blood pressure, diabetes, and dementia, is completely dependent on assistance for eating, as per their MDS assessment. This resident was also observed sitting at a dining table with their meal in front of them without receiving the necessary assistance. A nursing assistant acknowledged the lack of staff to assist with feeding and had not yet reported the need for additional help. The Assistant Director of Nursing confirmed the facility's failure to provide timely meal assistance, thus compromising the residents' right to a dignified dining experience.
Failure to Notify Physician of Change in Resident's Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition for one resident. The resident, who was admitted with diagnoses of hyperlipidemia and depression, was found to have skin issues including scratches on the right hip, raised patches on the abdomen and right side, and a yeast infection under the left breast. These conditions were noted by an aide and confirmed by a registered nurse, who instructed the application of anti-fungal and barrier creams. However, there was no documentation indicating that the physician was notified of these changes in the resident's condition. This deficiency was confirmed during an interview with the Director of Nursing.
Failure to Ensure Understanding of SNF ABN Form
Penalty
Summary
The facility failed to ensure that residents were given proper notice and understanding of their Medicaid/Medicare coverage and potential liability for services not covered. Specifically, the facility did not adequately explain the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) form to Resident R84, who had a BIMS score of 8, indicating moderate cognitive impairment. This score suggests that the resident may not have fully understood the implications of signing the SNF ABN form without proper explanation or assistance. The deficiency was identified during a review of facility admission documents and staff interviews. The Registered Nurse Assessment Coordinator (RNAC) confirmed that the facility did not ensure the SNF ABN was explained in a manner that Resident R84 or their representative could understand. This oversight was in violation of several Pennsylvania Code regulations related to admission policy, licensee responsibility, management, and resident rights.
Failure to Obtain Physician Order for Bed Placement
Penalty
Summary
The facility failed to obtain a physician order and develop a resident-centered care plan for the placement of a bed against the wall for Resident R42. The facility's policy on physical restraints, last reviewed on 11/8/24, mandates that restraints should only be used as a last resort and must be justified by medical symptoms. However, during an observation and interview on 11/14/24, it was confirmed by Nurse Assistant Employee E12 that Resident R42's bed was positioned against the wall without a physician's order. The Director of Nursing also confirmed this oversight. Resident R42's clinical record indicated diagnoses of coronary artery disease, hypertension, and hyperlipidemia. The resident's care plan, revised on 10/1/24, aimed to prevent falls but did not include the placement of the bed against the wall. This oversight was a violation of the facility's policy and resident rights, which state that residents should be free from restraints unless medically necessary. The facility's failure to adhere to these policies resulted in a deficiency as per the cited Pennsylvania Code regulations.
Failure to Provide Privacy Cover for Catheter Bag
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with an indwelling urinary catheter. The facility's policy on indwelling urinary catheters, last reviewed on 11/8/24, requires that catheters not medically justified be discontinued as soon as clinically warranted and that catheter bags have a privacy cover unless one is built in by the manufacturer. However, during an observation on 11/12/24, it was noted that the resident's foley catheter bag was hanging on the bed frame without a privacy cover, which was confirmed by an LPN. The resident in question was admitted with a diagnosis of anemia, hypertension, and neurogenic bladder, and had a physician's order for a 16 French foley catheter with a 10cc balloon. The resident's care plan also indicated the use of an indwelling foley catheter related to neurogenic bladder. Despite these documented needs, the facility did not adhere to its policy regarding the privacy cover for the catheter bag, leading to the deficiency noted in the report.
Failure to Maintain Communication with Dialysis Center
Penalty
Summary
The facility staff failed to maintain ongoing communication with the dialysis center for two residents, leading to a deficiency in providing safe and appropriate dialysis care. Resident R57, diagnosed with anemia, hypertension, and end-stage renal disease (ESRD), was to receive dialysis three times a week. However, the review of dialysis communication sheets revealed that two out of 21 sheets were not completed prior to dialysis sessions. Similarly, Resident R59, diagnosed with heart failure, hypertension, and ESRD, also required dialysis three times a week. The review showed that 18 out of 20 communication sheets were not completed before dialysis sessions. During interviews, an LPN admitted that the top portion of the dialysis sheets was not normally filled out, while an RN acknowledged the necessity of completing this section and sending the book along with any order summaries. The Director of Nursing confirmed the incompleteness of the dialysis books and the failure to maintain communication with the dialysis center for the two residents. This lack of communication and documentation was identified as a deficiency in the facility's compliance with the required standards for dialysis care.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that residents are free from significant medication errors, as evidenced by the case of one resident who did not receive their prescribed medication, Mercaptopurine, on two consecutive days. The facility's policy requires that physician orders are followed and medications are administered as prescribed. However, the resident's Medication Administration Record indicated that the medication was not available on the specified dates, leading to missed doses. Additionally, the clinical record did not show any evidence that the physician was notified about the missed doses of Mercaptopurine. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged the failure to prevent significant medication errors for the resident in question. The deficiency was identified under several Pennsylvania Code regulations related to nursing services, resident rights, resident care policies, and pharmacy services.
QAA Meetings Lacked Required Members
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all required committee members for the period of January 2024 through March 2024. The facility's policy, dated 7/22/24 and last reviewed on 11/8/24, mandates that the QAPI Committee should include specific members such as the Nursing Home Administrator, Director of Nursing, Medical Director, and others. However, a review of the QAPI Committee meeting sign-in sheets revealed that the Medical Director/designee and Infection Preventionist were not in attendance during this period. This deficiency was confirmed by the Nursing Home Administrator during an interview on 11/15/24.
Failure to Provide Effective Communication Training
Penalty
Summary
The facility failed to provide mandatory training on effective communication for one of its staff members, specifically a Nurse Aide (NA) identified as Employee E9. According to the facility's Employee Handbook, all employees are required to participate in mandatory training programs to maintain the necessary skills for superior resident care. However, a review of NA Employee E9's personnel file revealed a lack of documentation for effective communication training between November 14, 2023, and November 14, 2024. This deficiency was confirmed during an interview with the Director of Nursing on November 14, 2024.
Failure to Use Safe Transfer Method for Resident
Penalty
Summary
The facility failed to ensure that residents were free from neglect by not using the safest transfer method for a resident, identified as Resident R2. Resident R2, who was diagnosed with depression, Alzheimer's disease, and anemia, was dependent on mechanical lift assistance for transfers as per physician orders and care plan. However, during a transfer from a shower chair, three Nursing Assistants (NAs) manually lifted the resident without using the mechanical lift, resulting in a popping sound from the resident's shoulder. Although initially assessed with no noticeable injuries, swelling was later observed, and the resident, who is nonverbal, showed signs of pain. Interviews with the involved NAs revealed a lack of adherence to the prescribed transfer method. NA Employee E1 acknowledged knowing the resident required a mechanical lift but cited the unavailability of a hoyer pad as the reason for manual lifting. NA Employee E3 admitted to not knowing how to verify a resident's transfer status and assumed the resident required less assistance due to her small stature. The Director of Nursing confirmed the incorrect transfer method was used, and both the Nursing Home Administrator and the Director of Nursing acknowledged the facility's failure to prevent neglect by not adhering to the safest transfer protocol for the resident.
Inadequate Supervision and Transfer Practices
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for residents, resulting in an elopement incident involving a resident with Huntington's Disease, malnutrition, and a personality disorder. The resident, who was cognitively intact according to a recent assessment, was able to leave the facility unsupervised despite being in an enclosed courtyard. The resident had a history of refusing to wear a wander guard, a device meant to alert staff if a resident approaches an exit. On the day of the incident, the resident was left unsupervised for approximately two minutes, during which time they exited the courtyard and were found outside the facility. This incident highlighted the facility's failure to complete timely and accurate wandering and elopement risk evaluations for residents, as well as the lack of physician orders to check the function of wander guards. Additionally, the facility failed to ensure safe transfer practices for another resident diagnosed with depression, Alzheimer's disease, and anemia. The resident was dependent on mechanical lift assistance for transfers, as indicated in their care plan and physician orders. However, during a transfer from a shower chair, three nursing assistants manually lifted the resident without using the mechanical lift, resulting in a popping sound and subsequent swelling in the resident's shoulder. The nursing assistants involved were unaware of the resident's transfer status and cited the unavailability of necessary equipment as the reason for not following the prescribed transfer method. The facility's policies on elopement prevention and resident protection from neglect were not adequately followed, as evidenced by the incidents involving both residents. The nursing home administrator and director of nursing confirmed these deficiencies, acknowledging the failure to provide adequate supervision and to adhere to safe transfer protocols. The report also noted that the facility's management and nursing services did not meet the required standards, as outlined in the relevant state codes.
Deficiency in Shower Room Cleanliness and Safety
Penalty
Summary
The facility failed to provide a clean, safe, and homelike environment in one of its shower rooms, specifically the Miller's Crossing Nursing Unit shower room. During an observation, it was noted that the shower stall had a brown substance on the back wall, and the flooring had a buildup of debris and grime along the baseboard and corners. Additionally, the baseboard was not properly secured, posing a potential risk for resident injury. These findings were confirmed by the Nursing Home Administrator during an interview.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
The facility failed to ensure that residents were free from neglect by not providing adequate supervision for one of three residents, resulting in an elopement. Resident R1, who had severe cognitive impairment with a BIMS score of 5, was found in the Personal Care building after wheeling through the cafeteria. The facility's policy defines neglect as the failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress. Despite the resident's known condition and the need for increased supervision, the facility did not adequately monitor Resident R1, leading to the elopement incident. The Director of Nursing (DON) and RN Supervisor failed to complete necessary post-elopement procedures, including an incident report, witness statements, and a new Wandering Risk Assessment. The RN Supervisor admitted to not assessing Resident R1 after the elopement and did not complete an incident report, believing it was unnecessary since the resident was unharmed. The facility's lack of communication and procedural follow-through contributed to the failure in providing adequate supervision, as confirmed by the DON and Nursing Home Administrator. Additionally, the State Agency was able to exit the unit and enter the Personal Care Home without restricted access, highlighting the facility's inadequate security measures.
Failure to Investigate Elopement Incident
Penalty
Summary
The facility failed to implement written policies and procedures to ensure a complete and thorough investigation of an incident involving the potential for neglect, resulting in an elopement of Resident R1. Resident R1, who had severe cognitive impairment with a BIMS score of 5, was found in an unauthorized area by Personal Care staff. The RN Supervisor did not complete an incident report or conduct a post-elopement assessment, and the facility was not aware of the elopement until the following day. The Director of Nursing confirmed that there was a breakdown in communication and that the required documentation and assessments were not completed. During interviews, the RN Supervisor admitted to overhearing that Resident R1 was found in Personal Care but did not take further action because the resident was not harmed and did not make it outside the facility. The Nursing Home Administrator and Director of Nursing confirmed that the facility did not obtain witness statements from staff on duty at the time of the elopement and failed to follow their own policies and procedures for investigating such incidents.
Failure to Investigate Elopement
Penalty
Summary
The facility failed to conduct a thorough investigation of an elopement involving a resident with severe cognitive impairment. The resident, who had diagnoses of high blood pressure, dementia, and muscle weakness, was found in an unauthorized area without the facility's knowledge. The incident was not reported immediately, and no physical assessment, vital signs check, or Wandering Risk Assessment was completed after the resident was returned to the facility. The Director of Nursing (DON) confirmed that the RN Supervisor did not complete an incident report or obtain witness statements from staff on duty at the time of the elopement. The RN Supervisor admitted to overhearing that the resident was found in the Personal Care building but did not take any action because the resident was not harmed. The supervisor did not assess the resident, call the physician, complete an incident report, or update the care plan as required. The Nursing Home Administrator and DON acknowledged that there was a breakdown in communication and that the facility failed to conduct a thorough investigation to rule out neglect. The facility's policies on Resident Protection from Abuse, Neglect, Mistreatment, or Exploitation and Elopement Prevention were not followed, leading to the deficiency.
Failure to Update Care Plan After Resident Elopement
Penalty
Summary
The facility failed to ensure that a resident's care plan was updated and revised to reflect the resident's specific care needs after the resident eloped from the facility. Resident R1, who had severe cognitive impairment with a BIMS score of 5, was found in an unauthorized area after wheeling through the cafeteria and into Personal Care. Despite this incident, the resident's care plan did not include goals and interventions related to the elopement. The facility's policy on Elopement Prevention requires that a comprehensive elopement prevention plan be documented as part of the care plan, and the Care Plan and Interdisciplinary Care Conferences policy mandates that the care plan be reviewed and updated based on ongoing assessment and evaluation of resident needs. However, these policies were not followed in this case. During interviews, the RN Supervisor admitted to not assessing Resident R1 after the elopement, not completing an incident report, and not updating the care plan, as the resident was not harmed. The Director of Nursing confirmed that the facility failed to update and revise the care plan to reflect the resident's specific care needs after the elopement. This deficiency was identified for one of three residents reviewed, indicating a lapse in adherence to the facility's policies and procedures for care planning and elopement prevention.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
The facility failed to ensure adequate supervision for Resident R1, resulting in an elopement incident. Resident R1, who had severe cognitive impairment as indicated by a BIMS score of 5, was found in the Personal Care building after wheeling through the cafeteria. The facility's policy on Elopement Prevention required a comprehensive elopement prevention plan and regular Wandering Risk Assessments, which were not completed following the incident. Additionally, the facility's policy on Accidents and Incidents mandated a physical assessment, vital signs check, and a risk management report, none of which were performed after Resident R1 was returned. The RN Supervisor failed to complete an incident report or conduct a post-elopement assessment, as confirmed by the DON. The RN Supervisor admitted to overhearing about the elopement but did not take any action because Resident R1 was not harmed. This lack of action was a breakdown in communication, and the facility was not aware of the elopement until the following day. The RN Supervisor also failed to update the care plan or complete a new Wandering Risk Assessment. During a tour of the facility, it was observed that the Fairgrounds Village Unit could be exited through the Settlers Dining Room and into the Personal Care Home without restricted access. This allowed Resident R1 to elope without being noticed by staff. The Nursing Home Administrator and DON confirmed that the facility did not provide adequate supervision, leading to the elopement incident for Resident R1.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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